To Have, Not Hold

A second brain and a place to garden

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Hi Timeless Autonomy Community,

Clinicians sometimes ask those of us working in non-clinical jobs how we got there. There are so many ways to answer this and I’ve probably explained my path 20 different ways.

But the most accurate reason why my career path took me down the windy road from physical therapist to health policy professional is because I ask myself “why.” A lot!

Then I try to find ways to solve the problem, if I found one, that’s a win/win/win. I would think about and anticipate the obstacles to my solutions and how to overcome them—

“How can we change this or get to this result so all the stakeholders have some incentive to participate/comply?”

Here’s an example from my career where I asked “why.”

I was a few years out of PT school and had worked at an inpatient rehab facility (IRF), outpatient rehab, and some per diem home health extra work. I went to full-time home health to have flexibility when I was gearing up for motherhood, and because I already knew I wasn’t going to thrive in the strict and limiting schedule of many other settings.

I wanted as much autonomy as I could find in a full-time PT role.

When I got there, I brought to my new boss an opportunity I found. It stemmed from something that had bothered me.

I told him how it didn’t make sense that inpatient rehab facilities admitted so many patients with total joint replacements. I was seeing patients with strokes, amputations, and traumas, and then a third of my caseload was total joint replacement patients.

The thing was, they didn’t really need to be there.

But no one else was saying that, so for a while, I thought I was nuts. Novice behavior.

The other patients who had major events that required skilled, intense, inpatient, team-based rehab? They needed to be there.

So I tried to figure out what the root cause was. How did we get here?

I did some desktop research (the best kind! 😄 ).

The reimbursement to the IRF from Medicare was high. The rehab complexity was low. Patients expected it.

Physicians could hand-off the surgical patient and know they wouldn’t hear from the patient for 1-2 weeks.

Patients could generally tolerate the amount of therapy per day.

But was it medically necessary? Rarely.

I made some connections.

Patients going to inpatient rehab after a total joint replacement usually discharged to outpatient therapy. That meant the home health agency wasn’t usually participating in the episode.

But if we could change the trajectory of care and select appropriate patients to discharge home with home health instead of IRF, it would be good for patients to be home and functioning after surgery and good for the home health agency, with a new referral source and “product,” although I didn’t know that term then.

We created “Rapid Rehab” in 2002. This was wayyyy before the Affordable Care Act. We had essentially created an episodic model that saved money for CMS (about 12-15k difference in IRF vs. home health, but I don’t recall a thank you note 🙃 ), provided an option for patients to discharge to their preferred site after surgery, created a new revenue stream for the HHA.

And we were inadvertently preparing for the CMS bundled payment models and demonstrating how to make them work (save money, improve quality).

What does this have to do with “To have, Not Hold?”

I didn’t realize, but I had developed a “capture habit.” When I made a connection or figured out a piece of a problem, I wrote it down on a notecard. I kept it on the end table next to my bed. Once in a while I flipped through the notecards and keep the information “alive” for me. I’d make notes on the back if the original note helped me make a new connection in my mind.

So when I found an opportunity to connect dots, I did.

The home health agency was growing the rehab department.

Orthopedic patients often need more therapy than nursing in home health.

What orthopedic patients were we getting and from what referral sources? What was missing?

Where were different patient types with different conditions going after the hospital? Why?

And then my notecard came up in my casual note review one night, shortly after I began my full-time role in home health. (I wish I kept that card to this day!). It said it didn’t make sense for patients to be admitted to the IRF and be ambulatory quickly, while most of my other patients needed significant hands-on help, often of 2-3 people, and many still needed significant assistance at discharge, too. Why couldn’t they go home with home health and get a little extra support in the first few days they were home, if needed?

The rest fell into place.

Your brain is for having ideas, not holding them

We have an idea and we think “I’ll remember this.” And we don’t.

We read an article in an email newsletter and think “That’s interesting, I’ll come back to that and I’ll remember why something in there resonated.” But we don’t.

Everyone needs a “capture habit.”

Capturing information and ideas systematically is the most important thing I’ve done for my career. No one told me to do it, and it was rudimentary. But it felt good to have these little valuable nuggets that were mine.

But information is so voluminous now, it’s like drinking from a fire hose every day. There have to be systems now. And there are much better ways than my old system.

(My original analog “system” was closer to the Zettelkasten system, actually, but not as sophisticated. If you’re curious, read more here.)

Enter the Second Brain

Tiago Forte developed the term “second brain.” It involves the process where we

  • Capture

  • Organize

  • Distill

  • Express

information.

Let’s break that down. Well, let’s let Tiago Forte break that down. 😁 

Capture

Organize using the PARA Method 👇️ 

Distill into concentrated summaries 🧪 

Your notes should be written for your future self.

Summarize a few times until you get there

Express

Tiago Forte says to share your work with the world. Another favorite creator has another great expression for this. Austin Kleon and “Show your Work!”

Tiago Forte

Austin Kleon

Here’s Tiago Forte five years ago, talking about “Building a Second Brain” to capture, organize, and share ideas:

And this is right on Tiago’s home page in his list of reasons to build a second brain:

Maybe you’re dissatisfied with your current job and want to move to a more fulfilling career and get more out of life. 

Or maybe you have a lot of ideas and expertise but don’t know how to link all that information together to make the impact you want to make. 

So if you just want to improve your career growth and trajectory, want to find new directions you can take yourself through using knowledge and creativity, think about building a second brain!

I can cover tools I use for my second brain building and talk more about what personal knowledge management looks like. I’m really only an intermediate level at this point. I’m still discovering, and it’s so much fun to do!

On gardening your second brain

This is a term used to describe one type of second brain system or style, and some second brain tools are more easy to adapt to this style.

Your second brain should be a place you can go to connect ideas, take action on projects, express new content, build projects, and so much more.

Just like a garden, it should be tended to now and again.

I pulled this from a website (it may be a personal blog?) that was saved in my personal knowledge management app:

Next post—the apps I use, what “tending the garden” looks like, “sparkly object syndrome,” and more about the Second Brain and careers.